Federal Reports

The VA Office of Inspector General (OIG) conducted this review to determine if the Veterans Health Administration (VHA) completed radiology and nuclear medicine exam requests and follow-up care in a timely manner. The audit team also reviewed two related hotline allegations and determined if VHA managed canceled requests appropriately nationwide. The audit team estimated that 17 percent of routine exams and 25 percent of urgent exams were not completed within the required time frames. Reasons included staff and equipment shortages, issues with staff allocation, and insufficient monitoring of the scheduling process. Additionally, facility staff did not consistently follow radiology and nuclear medicine policy for canceled outpatient requests. Inappropriate cancellations can lead to delayed or incomplete exams and increase patient wait times. The audit team found that most follow-up care was completed appropriately. Facility staff either attempted to complete the recommended follow-up care with veterans or confirmed that they received it. The OIG made several recommendations to the under secretary for health to address management issues on the facility and regional levels. Among the recommendations were ensuring that facility staff evaluate the workload for scheduling exam requests and monitor requests that have been pending for more than seven days, implementing a mechanism to routinely audit canceled exam requests and take corrective action as needed, developing and implementing a plan for improving radiology and nuclear medicine oversight regionally, and creating a method for sharing new guidance with radiology and nuclear medicine leaders. The audit team also substantiated allegations of inappropriate exam cancellations at the James A. Haley and Iowa City VA medical centers. The issues were addressed in the general recommendations.

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Audit of recurring accounting entries for the NLRB's backpay financial records.

This report assesses the effectiveness of the company’s controls to mitigate the risk of fraud in its payments to non hospital facilities. We focused on claims the company paid to the top tenth percentile of non hospital facilities from 2014 through 2018.Just as with our previous work on medical claims, we found that the company is exposed to potential fraud in its medical claim payments and has not obtained a capability to proactively analyze its medical claim payments for potential fraud. Notably, Amtrak is self insured and pays for each medical claim as they are incurred from its operating budget.Among the medical claims of non-hospital facilities we reviewed, we identified 191 that exhibited billing patterns indicative of fraud. The company had not flagged the billing patterns of these facilities for further review. This has put at risk an estimated $57 million the company paid to these facilities between 2014 and 2018. To address the findings in our report, we recommend the company do the following:• Review claims paid to the 191 potentially fraudulent facilities and seek recovery of whatever portion of the $57 million in claims it determines were improper.• Implement proactive fraud detection procedures sooner, so that the company can stop fraudulent payments earlier. • Implement fraud awareness initiatives to enable plan members to better recognize and report potential fraud. • Gather information on fraud schemes and emerging fraud trends and use it to monitor its medical claim payments.

We undertook this study because of concerns that Medicare Advantage organizations (MAOs) may use chart reviews to increase risk adjusted payments inappropriately. Unsupported risk adjusted payments are a major driver of improper payments in the Medicare Advantage (MA) program, which provided coverage to 20 million beneficiaries in 2018 at a cost of $210 billion. CMS risk-adjusts payments using beneficiaries' diagnoses to pay higher capitated payments to MAOs for sicker beneficiaries?which may create financial incentives for MAOs to make beneficiaries appear as sick as possible. MAOs report these diagnoses via CMS's MA encounter data system based on services and chart reviews (i.e., MAO's reviews of a beneficiary's medical record to identify diagnoses that a provider did not submit or submitted in error). For a diagnosis to be eligible for risk adjustment, it must be documented in a medical record as a result of a face to face visit. Although CMS requires MAOs to identify chart reviews in the encounter data, CMS does not require MAOs to link these chart reviews to a specific service associated with the diagnoses. This may provide MAOs opportunities to circumvent CMS' face-to-face requirement and inflate risk adjusted payments inappropriately.